ALMA, MI- MICHIGAN MASONIC HOME

Based on observation, interview and record review, the facility neglected residents by failing to provide care and services for 4 resident’s (R4, R6, R7, R8) and residents on the 1 South Unit on 11/23/21, reviewed for being at risk for abuse and neglect, resulting in an Immediate Jeopardy (IJ) that began on 11/23/21, as a result of the facility’s failure to provide incontinence care and reposition residents leading to R4 having pain and discomfort, R6 developing an unstageable pressure ulcer, multiple Stage II ulcers, experiencing pain, R8 developing multiple stage II ulcers and experiencing pain, R7 experiencing pain and Residents on 1 South having the potential for skin breakdown and pain. R7 and R6 experienced neglect, pain and delayed care after a lack of thorough investigation into the neglect of R4 and R8 being reported to facility administration. This deficient practice has the high likelihood to affect all residents in this facility potentially resulting in further neglect, harm, serious injury or death.

On 12/1/21 at 9:20 AM, R6 was observed in bed. He was on his back and the head of bed was elevated 30 to 40 degrees and he was covered with a blanket. Registered Nurses (RN) O and P were in his room attempting to reinsert an IV (Intravenous) line. They reported he had pulled it out this morning and they were not able to get it back in. They said they were contacting another nurse in the facility and if they were not able to get it started, they would send him to the emergency room . R6 was complaining of pain in his buttock at that time. The Surveyor asked R6 if she could look at his buttock with the nurses to see if they could determine the cause of his pain. R6 agreed. R6 yelled out in pain several times with lowing the head of his bed and turning him. When the nurses removed R6’s brief it was soiled with bowel movement but not wet. There was no indication he had soiled himself until the brief was pulled back. There was a large white pad/dressing placed over R6’s left hip. No date or time was visible on the dressing. When the dressing was removed there was a large area, approximately 4 inches by 2 inches of black tissue with a bright red border. RN O called for a CNA to come into clean R6 up. RN O said she had 3 CNA’s on her unit since 6:00 AM and normally had 2 CNA’s. RN O the CNAs were L, M, and N.

On 12/1/21 at approximately 9:30 AM, CNA M came to R6’s room to clean him up. CNA M said she had not seen R6’s buttock prior to this time today. RN O started helping CNA M clean up R6 and when CNA N arrived RN O instructed them to finish cleaning him up and off load his buttock on the left. CNA N said she had not seen R6 buttock prior to this time today and confirmed she started at 6:00 AM. Once R6 was cleaned up and new brief was on he was placed on his back and two bed pillows were tucked in between the mattress and his hips. There was a pillow under each hip which placed pressure directly on the large wound on R6’s left hip and increased pressure to his right hip. This prevented any rolling or contact of the specialty pressure reliving mattress to the pressure ulcer area. The Surveyor questioned the CNA’s as they had just been instructed to off load pressure from R6’s left hip. Both CNAs responded the facility had educated them that this was how to off load the buttock. They were not able to recall who educated them or when they were educated.

On 12/1/21 at 9:50 AM, RN O was at the nurses station. RN O reviewed R6’s wound assessments
documented in the electronic medical record (EMR). There was a picture of the wound on R6’s left hip that was measured at greater than 9 cm x 4 cm and was covered with eschar (black tissue). The wound was labeled as a stage II ulcer. The Surveyor asked RN O if that was a stage II ulcer and RN O responded no it is unstageable. When questioning how it could be mislabeled RN O explained she had made the error when it changed from a stage II to unstageable. RN O went on to explain when she has days off agency nurses cover for her and they do not know how to run the camera or how to do many of the things that need to be done. When RN O returns to work she has to do the work of 2 nurses due to all of the things that were not completed when she was off. RN O was frustrated about her workload that contributed to her charting error. The Surveyor told RN O that the CNAs had placed pillows under both sides of R6’s buttock and had told the Surveyor this is how the facility had educated them to off load resident to prevent pressure ulcers. RN O verified R6’s pressure ulcer was not off loaded as she had instructed. 

Review of R6’s emergency room report dated 12/1/21 at 4:25 PM revealed, he had an ulceration along the left gluteal crease with [CONDITION(S)] and large abscess (infection)in the subcutaneous soft tissue extending to the deep fascia (tissue) measuring 12.5 cm. The plan was to do debridement (remove dead and infected tissue) of the wound 12/2/21. Under Number of diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Discussed CT findings of abscess underlying gluteal ulcer and resultant [CONDITION(S)] with surgery. Patient to be admitted for surgical debridement as well as IV Abx (antibiotic’s).